CNS - HN - Syncope Flashcards
Differentials of Syncope
- Prolonged QT syndrome
- Aortic Stenosis
- Vasovagal
- Postural orthostatic hypotension - polypharmacy
- Postural orthostatic hypotension
- Postural orthostatic hypotension with Stroke
- Seizure due to binge drinking
- Diabetic Neuropathy
- Hypoglycemia
- TIA
- Seizure and subdural hematoma
- Seizure - idiopathic epilepsy
- Comatose
1. CNS - SAH TIA/STROKE (case) Epilepsy Migraine Meningitis Seizure
2. CVS- HOCM Arrythmias WPW Aortic Stenosis (case) Prolonged QT (case)
- Vasovagal - case
Long standing
4.Reflex-micturition, defecation, cough syncope
- Orthostatic Hypotension - case
polypharmacy
6. Metabolic Hypoglycemia - case Electrolyte imbalance (decreased K, Mg, Ca)
7. Medications Drug-induced: side effect of antipsychotic (most common cause) Abnormal Prolonged QT Syndrome Drugs • Amiodarone • Procainamide • Quinidine • Tricyclic antidepressants/Antipsychotic • Sotalol • Dizopyramide
- Trauma
- Malignancy
- Psychogenic
Differentials of Syncope
CNS
1. CNS - SAH TIA/STROKE (case) Epilepsy Migraine Meningitis Seizure
Differentials of Syncope
CVS
2. CVS- HOCM Arrythmias WPW Aortic Stenosis (case) Prolonged QT (case)
Key history - SYNCOPE / FALL
A careful history is required including an interview with family members and any witnesses to the fall.
Investigate the onset, environment and circumstances of the fall.
Consider seizure and loss of consciousness, and situational factors such as rushing to bathroom, climbing stairs or ladder. Incl. accounts of any witnesses to the fall.
Questions should incl. any premonitory or associated symptoms e.g. vertigo, lightheadedness, palpitations, chest pain dyspnoea, visual disturbance, possible unusual or disturbed behaviour.
Gather past and recent medical history incl. diabetes, hypertension, cerebrovascular disease; as well as a drug history, esp. alcohol or illicit drugs, prescription agents esp. sedatives antidepressants, hypotensives, hypoglycaemics, antipsychotics, diuretics, NSAIDs. Check thyroid status.
Key Physical examination - SYNCOPE / FALL
Key examination
•General features: appearance of patient incl. central cyanosis, hydration status, vital signs incl. pulse, BP (supine and standing) and temperature
•Look for and exclude obvious extrinsic causes of falls
•Comprehensive CVS examination
•Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet
•Neurological examination including muscle features, sensation, coordination, balance and gait
•Mini mental state examination
Key Investigation - SYNCOPE / FALL
First line: •urinalysis •blood sugar •pulse oximetry •FBE & ESR •U&E •ECG (or 24 hour monitor).
Consider others according to history and findings: •LFTs (γGT) •TFT •echocardiography •spinal X rays •CT or MRI if indicated •Doppler studies
Diagnostic Tips
Consider rules of 7 in elderly patient:
- check mental status
- eyes
- ears
- mouth (?dentition, xerostomia)
- bladder and bowels,
- locomotion including feet
- medication.
Ideally, visit the home to assess patient’s environment and home support, incl. examination of the medicine cabinet.
Prolonged QT - Management
Investigations
- FBE, UE, BSL, betaHCG, TFT, LFT, Chest XRay, ECG.
Treatment:
- Admit
- Refer to Cardiologist/ Registrar
- Beta blocker if fails put on pacemaker
- I will also arrange a family screening for this condition (only say this if congenital)
Aortic Stenosis - Management
Investigations:
- FBE, UEC, ESR/CRP, LFT, RFT, TFT.
- ECG, and chest x-ray,
echocardiogram.
Treatment
- Admit to hospital
- Seen by specialist
- LSM - SNAP
- Avoid strenuous activity
- Surgery - Valve replacement
Vasovagal - Management
Investigations
- FBE, UCE, LFT, TFT, BSL,
- ECG
- Admit for observation
- Seen by registrar
- Do’s & Don’ts
- Don’t skip breakfast esp prior to activity/ avoid prolonged standing
- Hydration
- get up from sitting/lying slowly
POH - Management
Investigation
- FBE, ESR,CRP, LFT, UCE, TFT, BSL, lipid, HbA1C,
- ECG, echo
- Admit for observation
- Seen by specialist
- Once discharged, refer back to DM physician/cardio for review of meds
- Advise
DM control
IOF
Get up slowly
POH Stroke - Management
Investigations
- FBE, BSL, UCE, ESR CRP, - LFT, TFT,
- Urinalysis
- ECG, CT scan
- Refer to fall clinic
- MDT approach
- Monitor VS regularly
- Refer to Ophtha and ENT
- Refer to physiotherapist
- Refer to OT
- Refer to Social worker
- they might change medication dose accordingly
Seizure d/t Binge Drinking - Diagnosis
Condition - Binge drinking - imbalance of salt in body - dehydration - decrease sugar in body
Common
Cause
Clinical feature
Complication
no management
*Ddx
Diabetic Neuropathy - Diagnosis
Condition -
DIabetic Neuropathy
high sugar» sensory loss
Common
Cause
Clinical feature
Complication
no management
*Ddx - vision problem, arthritis, mini stroke
Hypoglycemia - Diagnosis
Condition -
Hypoglycemia
BSL <4mmol
Common
Cause - MEDIKA Meds Exercise Diet Infection Kidney problems Alcohol
Clinical feature
Mild
- hungry, sweaty, palpitation, shakes
Severe
- Loss of concentration, confusion, fits»_space; LOC
Complication
- if left untreated coma»_space; life threatening
Hypoglycemia - Management
Immediate management
If <4mmol/L, give 15 grams quick acting carbs
- 6 jelly beans
- tsp honey
- 2 barley sugar
- glass of lemonade
After 15 mins, repeat BSL
If still unwell, repeat
If still unwell, follow with a complex carbohydrate
- sandwich
- glass of milk
- 1 pc of fruit
Severe cases
- 20-30 ml 50% glucose IV until fully conscious
- 1 ml Glucagon IM or SC
- then send to hospital
o Preventive measures: § Avoid skip a meal. § Do not change your dose on your own. § Avoid any unplanned activity. § Do not binge drink. §Maintain a blood sugar diary, check your blood sugar every day.
- Hypopack
- ID Badge
- 12 jelly beans
- 6 glucose tablets ( 1 tab = 5 grams)
- IM glucagon Injection
- Refer to dietician
- Refer to DM educator or nurse
- Reading materials
- Review
- Red flags
- Refer
Transient Ischemic Attack - Management
Investigations
- I will arrange for urgent CT scan and carotid Doppler
- Need to do FBS, lipid profiles, FBE, UEC, LFTs, ECG, 2d-echo, TFTs, clotting profile, HbA1c
- Refer to ED
- Admit to stroke unit
- Seen by neurologist
- clopidogrel or ASA + Dipyridamol
- LSM - SNAP
Idiopathic Epilepsy - Diagnosis
Condition -
Idiopathic Epilepsy
problem with electrical circuit of brain and NS»_space; unable to work properly
Common
1:100 M:F
familial
Cause
unknown
Clinical feature
Complication
Idiopathic Epilepsy - Management
- Aim of the treatment is to achieve complete seizure-control by one medication which is called monotherapy and lifestyle management
- Monotherapy» dose adjusted 70-80%effective 1st line drugs»if fail, replaced by another drug» 1st drug is stopped once the therapeutic effect of the 2nd one is achieved.
- LSM
- avoidance of triggering factors like
- fatigue
- physical exhaustion
- stress
- lack of sleep
- excess alcohol
- avoidance of flashing lights
- open fires
With proper treatment, most patients can achieve complete control of seizure and lead a normal life.
Meds
- Side effects: nausea, anorexia, vomiting, dizziness/drowsiness, tiredness or fatigue, gait disturbance like ataxia, visual disturbance, and most drugs can cause a rash.
o Sodium valproate: hair loss, rare but serious liver toxicity (LFTs every 2 months for 6 months after starting), NTD (spina bifida)
o Phenytoin: ginigival hyperplasia, hirsutism, fetal malformation (cleft lip and palate), CHD
Carbamazepine: anorexia, nausea, vomiting, dizziness, skin rash, tinnitus, diplopia, ataxia, tiredness and fatigue; safest in pregnancy
- Reviewed annually, med stop if seizure free for 2-3 yrs
- The applicant applying for learner’s license should be seizure-free for 2 years then annual review for 5 years.
-contact centerlink, social support/worker; should not work close to heavy machinery, dangerous surroundings, heights, or near deep water; jobs not allowed: public transport (bus driver), police, military, aviation - Avoid scuba diving, hanggliding, parachuting, rock climbing, car racing and swimming alone especially surfing; contact sports: relative CI
- can expect to have normal sexual life and normal children and your children have a slightly increased chance of having epilepsy (3%).
- Red flags: Take special care with open fires, do not swim unsupervised
- Advice for carers:
o Do’s: roll person on to his side with head turned to one side and chin up and call for medical help if convulsion lasts longer than 10 minutes
o Don’ts: move person unless necessary for safety, force anything into person’s mouth, try to stop the fit - Regular follow-ups: monitor medication levels and side effects of the drugs
- Refer to support groups
- Reading materials
- In female patients: interaction with OCP so increased doses; if patient wants to get pregnant (high-risk pregnancy) à start patient on 5mg folic acid; planned pregnancy; NO contraindication for breastfeeding
COMATOSE - PE
Examination
- Inspection for any bruises, lumps/bumps, bleeding, signs of trauma (raccoon eyes, battle sign, bleeding from ears, nose), jaundice, facial asymmetry, check PEARL (miosis: pontine lesions, opioid overdose; dilated: raised ICP; signs of multiorgan failure, funduscopy for raised ICP and diabetic/HTN changes), neck stiffness, mouth for tongue bite marks
- Face: breathing pattern (metabolic acidosis à DKA, hypoventilation, drug overdose), smell of the breath (DKA – fruity smell, alcohol, fetor hepaticus and uremic coma)
- Peripheries: Tone, IV drug marks/insulin injection marks, snake bite, circulation, pulse oximetry, temperature, hydration
- Heart: arrhythmia
- Urine dipstick and BSL
COMATOSE - INVESTIGATIONS
Investigations
Blood:
FBE, blood cultures, ESR/CRP, LFTs, blood or urine drug screen, Urea & Electrolytes, RFTs, TFT
Urine:
Drug screen
Imaging:
cranial CT scan,
lumbar puncture
